Haryana

Karnal

CC/94/2019

Malkhan Singh - Complainant(s)

Versus

The Managing Cirector/Authorized Signaory, Apollo Munich Health Insurance Company Limited - Opp.Party(s)

Suraj Kanwar

04 Jun 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                         Complaint No.94 of 2019

                                                         Date of instt. 21.02.2019

                                                         Date of decision:04.06.2019

 

Malkhan Singh son of late Shri Ratti Ram, resident of House no.1859, Sector 9, Urban Estate, Karnal.

                                                                                                                                                                               …….Complainant

                                        Versus

 

The Managing Director/Authorized Signatory, Apollo Munich Health Insurance Co. Ltd., Central Processing Center, 2^nd & 3^rd floor, ILABS Centre, Plot no.404-405, Udyog Vihar, Phase-III, Gurugram.

 

                                                                      …..Opposite Party.

 

           Complaint u/s 12 of the Consumer Protection Act. 

         

Before     Sh. Jaswant Singh……President.

                 Sh. Vineet Kaushik………Member

 

 Present:   Shri Suraj Kanwar Advocate for complainant.

                   Shri Jaipal Singh Advocate for opposite party.

                  

 

                   (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that the complainant has purchased a mediclaim policy (Optima Restore Policy no.AA00700425-01) from OP by paying its requisite premium/renewal as per his demands in the month of November, 2017 and the same was renewed in the month of November, 2018 for a period from 17 November 2018 to 16 November 2019. Complainant suffered some medical problem (severe pain in the abdomen), due to this reasons, he admitted in various hospitals i.e. Fortis Hospital, Mohali, Park Hospital, Karnal and Sir Ganga Ram Hospital, Delhi. Complainant being fully insured with OP requested for cashless claim vide ID no.542031/2 but the cashless claim was denied vide repudiation letter dated 01.01.2019 on the ground that “As per the available documents, we have observed that there is a non-disclosure of__Hepatitis-C__(Ailment) which may have an impact on policy and hence cashless approval would not be possible at this juncture.”

2.             Further, on 15.01.2019 complainant has received a notice for termination under section VI j of Optima Restore Policy no.AA00700425-01 mentioning the reason that complainant known case of Hepatitis-C since 2015 i.e. before policy inception. Both above mentioned letters dated 1.1.2019 and 15.1.2019 are illegal, null and void ab-initio, invalid and not binding on the rights of the complainant as the complainant was getting treatment from PGI, Chandigarh, on the advice of concerned doctor on 17.03.2015, he got conducted his medical examination/medical test, wherein, HCV Viral Load by TAQ Man was detected. However, after getting treatment from PGI, Chandigarh, he again got conducted his medical test qua the same disease on 24.04.2015 from Dr. Lal Pathlabs, wherein Hepatitis C Viral quantitative Real Time PCR was got conducted and Target not detected. Meaning thereby, as on 28.04.2015, complainant was not suffering from such disease. Again on 28.12.2015, the abovesaid test was got conducted from the abovesaid Lab and as per results, target not detected. So, it is ample clear that above-mentioned tests which were conducted on 28.04.2015 and 28.12.2015, complainant was not suffering from the disease Hepatitis C Viral. Hence the letters dated 1.1.2019 and 15.1.2019 aim towards illegal rejection of the claim and termination of the policy. Complainant was facing some medical problem and it was detected that he had “Perforated Gangrenous Appendicitis with Abscess,’ hence he was admitted for treatment at Fortis Hospital, Mohali on 30.12.2018 and tests were conducted on complainant. It is pertinent to mention here that in the column of past history, the concerned Doctor/Consultant General Surgery has also specifically mentioned that “H/O Hepatitis C virus positive in 2015 and took treatment at PGI and cured.” Furthermore tests for Hepatitis B and Hepatitis C were conducted on complainant at Fortis Hospital at Mohali on 31.12.2018 and result was non-reactive, which means that complainant is not suffering from Hepatitis C as on today also.

3.             It is further to pertinent to mention here that consultant who had been regularly examining complainant has himself mentioned in the discharge summary that the patient is not suffering from Hepatitis C virus. Furthermore, complainant remained admitted in Shri Ganga Ram Hospital Delhi from 07.01.2019 to 17.0.2019 for Complicated Acute Appendicitis with Perforation, periappendicular infection sepsis (E.Coli) right sided pneumonia with complicated parapneumonic effusion, there also test for Hepatitis C was conducted on 10.1.2019 and 12.01.2019 but the target was not detected. PGI Chandigarh reports also mentions that complainant was not suffering from Hepatitis C since 28.04.2015 also Fortis Hospital Mohali and Sir Ganga Ram Hospital Delhi the premier Medical Institution of India has also found that the patient was not suffering from Hepatitis C as on today also. The complainant purchased the policy in the month of November,2017 at that point of time complainant was not suffering from any Hepatitis C disease hence there is no occasion for complainant to disclose that he was suffering from any such disease at the time of the purchase of the policy. Before issuance of the policy complainant was medically examined by empanelled Hospitals of OP and nothing adverse was found in those examinations. Thus, the complainant had not been suffering from the disease Hepatitis C on which ground, the repudiation letter dated 1.1.2019 and notice of termination dated 15.1.2019 was illegal issued to complainant. In this way there was deficiency in service on the part of the OP. Thereafter, complainant issued a legal notice dated 1.2.2019 in this regard but it also did not yield any result. Hence complainant filed the present complaint.

4.             Notice of the complaint was given to the OP, who appeared and filed written version raising preliminary objections with regard to maintainability; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that vide cashless ID no.542031 on 31.10.2018 cashless request was received from Fortis Hospital, Mohali for his treatment. The patient/insured Mr.Malkhan Singh was admitted on 30.12.2018 for management of pain in abdomen for which surgical treatment lap. Appendectomy was done. CT scan reported renal cysts and complicated appendicitis, with estimated cost of Rs.1,20,000/-. Post reviewing the documents submitted, it was noted that the complainant was suffering from Hepatitis-C which was mentioned in doctor certificate of Fortis Hospital. It is further submitted that complainant had also provided the documents of year 2015 and from these documents it was clear that complainant was suffering from past medical history before policy inception which was not disclosed with OP at the time of taking the policy. So, due to non-disclosure of material facts relating to health condition of the complainant that the cashless request was rejected. Hence there is no deficiency in service on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

5.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C34 and closed the evidence on 31.5.2019.

6.             On the other hand, OPs tendered into evidence affidavit of Deepti Rustagi Ex.RW1/A and documents Ex.R1 to Ex.R6 and closed the evidence on 22.05.2019.

7.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

8.             The case of the complainant, in brief, is that he had purchased a Mediclaim Policy (Optima Restore) from OP in the month of November, 2017 and same was renewed up to November, 2019. The complainant suffering some medical problem (severe pain in the abdomen), due to which reasons, he was admitted in various hospitals. The complainant being a fully insured with OP, requested for cashless claim but the same was repudiated by the OP on 01.01.2019, with the reasons for non-disclosure of Hepatitis-C (ailment).

9.             Further, on 15.1.2019, complainant was received a notice for termination of the policy mentioned the reasons that complainant known case of Hepatitis-C since 2015 i.e. before policy inception.

10.            Further, the medical claim policy was purchased by the complainant in the month of November, 2017 at that point of time complainant was not suffering from any Hepatitis-C disease hence there is no occasion for complainant to disclose that he was suffering from any such disease at the time of the purchase of the policy. Before insurance of the Mediclaim policy to complainant, complainant was intensively medically examined by empanelled Hospitals of the OP and nothing adverse was found in those examinations. It is worth mentioning here that various tests were got conducted under the supervision of the consultants wherein no such disease (Hepatitis-C) was detected after 28.04.2015. Thus, complainant had not been suffering from the abovesaid disease (Hepatitis-C) on which ground, the repudiation letter dated 1.1.2019 and notice for termination dated 15.01.2019 was illegally issued to complainant with malafide intention and arbitrarily. The complainant had spent Rs.6,05,525/- for his treatment.

11.            The case of the OP is that vide cashless ID no.542031 on 31.10.2018 cashless request was received from Fortis Hospital, Mohali for the treatment of complainant. Post reviewing the documents submitted, it was noted that the complainant was suffering from Hepatitis-C which was mentioned in doctor certificate of Fortis Hospital. The complainant had also provided the documents of the year 2015 and from these documents, it was clear that complainant was suffering from past medical history before policy inception which was not disclosed by the complainant at the time of taking the policy. Due to non-disclosure of material facts relating to health condition of the complainant the cashless request was rejected.

12.            Admittedly, complainant had purchased a Mediclaim policy (Optima Restore) from OP in the month of November, 2017 and same was renewed up to November, 2019. The complainant was suffering some medical problem, due to that, he was admitted in various hospitals, the name of the hospitals are mentioned in Ex.C4 and Ex.C5. There is no dispute regarding the treatment and hospital bills (Ex.C6 to Ex.C27). The complainant had spent Rs.605525/-as per the bill details (Ex.C13).

13.            The cashless claim of the complainant was repudiated by the OP on the ground that complainant has been suffering from Hepatitis-C since 2015 i.e. before the policy inception, which was not disclosed by the complainant at the time of the purchase of the policy-Certificate (Ex.C28) was issued by the doctor of PGI, Chandigarh on 8.5.2019, in which it has been clearly mentioned that the complainant was diagnosed as a case of chronic Hepatitis-C which was treated in 2015 and became a negative for HCV RNA at the end of treatment as well as after three months of stopping the treatment. His liver stiffness also improved with the latest value of 4.8KPA (dated 25.5.2016) Thus, he has been cured of chronic Hepatitis C. Later he developed appendicitis in December, 2018, which was treated in other hospital. There is no relation of Hepatitis C with appendicitis.

14.            Further, as per report Ex.C31 Dr. Lal Path Labs dated 28.04.2015 in its result column the target was not detected and it was remarked in test report that sample does not contain HCV RNA. Moreover, as per report (Ex.C32), Dr. L:al Path Labs dated 28.12.2015, in its result column, the target was not detected and in the remarks that the sample provided does not contain HCV RNA. In other medical records, target was not detected.

15.            It is clear from the medical record that complainant was diagnosed as a case of chronic Hepatitis-C and same was treated in 2015 and became negative for HCV RNA at the end of the treatment. This facts has been clearly proved from the certificate Ex.C-28 issued by Dr. of PGI, Chandigarh and reports of Dr. Lal Path Labs (Ex.C31 and Ex.C32). Thus, we are of the considered view that at the time of taking the policy in question the complainant was not suffering from any disease. Thus, repudiation letter dated 01.01.2019 (Ex.C29) and notice for termination of the policy dated 15.01.2019 (Ex.C30) issued by the OP are not tenable and justified in the eyes of law. The claim of the complainant was repudiated on the baseless ground by the OP. Thus, the acts of the OP amounts to deficiency in service and unfair trade practice.

                Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.605525/- as treatment expenses to the complainant with interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OP to pay Rs.25,000/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses. This order shall be complied within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:04.06.2019

                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

               

                (Vineet Kaushik)

                    Member